Sometimes health professionals are unaware of the free resources available to their patients. In my opinion, registered dieticians are an underutilized profession.
Phil Galewitz, author (September 9, 2019 in KHN.org)
Louis Rocco has lived with diabetes for decades but, until he met
with a registered dietitian in August, he didn’t know eating too much
bread was dangerous for him.
“I’m Italian, and I always eat a lot of bread,” he said. After two
hour-long visits with a dietitian — including a session at his local
grocery store in Philadelphia — Rocco, 90, has noticed a difference in
“It’s helped bring down my sugar readings,” he said of changes in his
diet including eating less bread. “I wish I knew I could have had this
help years ago.”
After getting a referral this summer from his doctor, Rocco learned that Medicare covers personal nutritional counseling for people with diabetes or kidney disease.
The estimated 15 million Medicare enrollees with diabetes or chronic
kidney disease are eligible for the benefit, but the federal health
insurance program for people 65 and older and some people with
disabilities paid for only about 100,000 recipients to get the
counseling in 2017, the latest year billing data is available. The data
does not include the 20 million enrollees in private Medicare Advantage plans.
Health experts say the little-used benefit represents a lost
opportunity for beneficiaries to improve their health — and for the
program to save money by preventing costly complications from the diseases.
An estimated 1 in 4 people 65 and older have diabetes and 1 in 3 have chronic kidney disease. Kidney disease is often a complication of diabetes.
The prevalence of diabetes has risen markedly in the past 20 years and the condition is more common as people age.
Nationwide, there are 100,000 registered dietitians
— more than enough to meet demand, said Krista Yoder Latortue,
executive director of Family Food in Philadelphia, which employs about
50 dietitians including the one who visited Rocco. Medicare data showed
about 3,500 dietitians billed the program for nutritional counseling in
The problem may be that not enough physicians know about the Medicare benefit. Doctors have to refer patients to a dietitian.
Congress approved the benefit, which began in 2002, after studies found
medical nutrition counseling leads to improved health outcomes and
fewer complications for older patients. Under the preventive health
provisions of the Affordable Care Act, the counseling has been available
without out-of-pocket costs to Medicare beneficiaries since 2011.
Medicare pays for three hours of dietary counseling during the first
year the benefit is used and two hours in subsequent years. A doctor can
appeal to Medicare for additional nutritional therapy if the physician
believes it is medically necessary.
Larry Lipman, 70, of Falls Church, Va., said he was shocked to learn
he had diabetes earlier this year because he’s relatively thin and is an
When his doctor recommended meeting with a dietitian, he not only
said yes but also brought along his wife, who does most of the cooking.
“It was great because I could ask specific questions and get into the
nitty-gritty about how I eat, what I eat and when I eat,” said Lipman, a
“I’ve learned I needed to cut down on portion sizes of rice and other
things to keep my carbohydrates down,” he said. “I’m thinking more
about what I eat every time and staying away from Doritos and ice
Doctors shoulder some of the blame for patients not getting dietary counseling by failing to refer them to dietitians.
“It’s a lot easier to prescribe a medication than it is to discuss
the importance of nutrition and get patients to meet with a registered
dietitian,” said Dr. Holly Kramer, a Chicago nephrologist and president
of the National Kidney Foundation.
“I don’t understand how we have this burgeoning obesity and diabetes
epidemic and we are not using dietitians in our clinics for all these
patients, yet we are paying for all these things that mediate from the
disease process such as arthritis, dialysis and amputations,” she said.
Jennifer Weis, a registered dietitian in Philadelphia, said the
limited hours Medicare covers is frustrating given how difficult it is
to change behaviors in older adults.
“It’s better than nothing, but in my mind is not sufficient,” she said.
Doctors might not be aware of the Medicare option since “it’s a
challenge to keep up with what is a covered benefit and what is not,”
said Dr. Michael Munger, chairman of the American Academy of Family
Physicians who practices in Overland Park, Kan. He said that many
doctors who don’t practice with a large health system may not be
familiar with dietitians in their community.
For convenience, Munger said, he refers his diabetes patients to a
nurse practitioner in his office for nutritional counseling. But only
registered dietitians are covered under the Medicare benefit, so his
Medicare patients face a copayment for that service.
Nutritional counseling is not the only underused Medicare benefit that can prevent health complications.
Part of the problem, said Yoder Latortue in Philadelphia, is there is
a lot of misinformation about whom the public can trust on nutrition
“Everyone eats and everyone has an opinion,” Yoder Latortue said.
Lauri Wright, a Jacksonville, Fla., registered dietitian and
spokeswoman for the Academy of Nutrition and Dietetics, said the federal
Centers for Medicare & Medicaid Services sends out notices to
health providers once a year but more information is needed.
About 10,600 registered dietitians have enrolled to treat Medicare
patients, a CMS spokeswoman said. She said the agency has been advising
health providers about the benefit and promoting it to enrollees on its
website and its annual handbook that it sends to beneficiaries.
Still, “I think because only two diseases are covered by Medicare and
the rest aren’t, it falls off everybody’s radar,” Wright said.
This is an issue I’m constantly up against when I advocate for patient- clients. I always submit an authorization to release medical information, and remind myself to be patient, pleasant and persistent to get the information I need.
It’s Your Right To See Your Medical Records. It Shouldn’t Be This Hard To Do
[August 28, 2019 opinion written by Harlan Krumholz for NPR.org]
Americans have the right to access their medical records, but actually doing so is often complicated, slow and costly.
At a time when many insurers and health information technology
companies are busily assembling databases of hundreds of millions of
medical records, Americans find it difficult to get access to their own.
you try to get yours, be prepared for confusing policies, ill-informed
staff, wasted time and high costs. Even then, you may not get the
records you seek. And all of this is at odds with your federal rights.
Last week a relative of mine relayed a typical story. She requested her medical records in digital format, a right endorsed in federal statutes.
Now, two months later, she is still struggling to get them. The
hospital had contracted with a third party, and evidently this company
transacts only through snail mail.
My colleagues and I have previously investigated records access. In a study
published last fall, we surveyed 83 top American hospitals and found
discrepancies were common between the policies hospitals described on
patient authorization forms and what employees later said to patients on
On the forms, hospitals often did not provide an option to receive
the entire medical record in digital format. On calls, employees said
they would release the whole record. But most hospitals were out of
compliance with federal regulations by refusing to provide the documents
in the format requested by patients.
Many hospitals made it
expensive to get records. Despite federal guidance that records
delivered digitally should not cost more than $6.50, hospitals charged
as much as $541.50 for a 200-page record, often without mentioning other
In another study,
published in June, we showed how hard it is to get your radiology
images. Almost every institution could provide them only on CDs, an
antiquated technology. The cost could be as much as $75. If you wanted
images from departments outside radiology, then you would need to make a
separate request for each one.
In a preprint
recently published on medRxiv, an online platform that shares research
before it has been peer reviewed, researchers reported the results of a
study of people’s access to their medical records.
The authors include Deven McGraw,
former deputy director for health information privacy at the Department
of Health and Human Services’ Office for Civil Rights, who is now chief
regulatory officer at Ciitizen.
McGraw and her colleagues found that the majority of the more than
3,000 health care providers they surveyed were violating rights
concerning access to health care data. The most common failure was the
“refusal to send records to [a] patient or a [patient’s] designee by
e-mail.” Many health care institutions were also likely out of
compliance with the Health Insurance Portability and Accountability
Act’s limitations on fees.
Together, these studies show that
many health systems around the U.S. fail to comply with the law by
routinely violating people’s right to access their digital health
So what can you do to improve your chances?
First, know your rights.
You have the right “to inspect, review, and receive a copy of your
health and billing records that are held by health plans and health care
providers,” according to the website
of the Office of the National Coordinator for Health Information
Technology. You have the right to “correct your health record by adding
information to it to make it more accurate or complete.” A guide
from the Office of the National Coordinator can help you with the
details. By the way, these rights also apply to records created by
pharmacies, laboratories and insurers.
Second, be persistent.
The studies indicate that health care providers are often ill informed
about the law. To be successful, you may need to push. I know someone
who was about to be charged $450 for medical records, and by knowing her
rights she bargained the charge down to a reasonable amount, though
still out of compliance with the law. If you want your records, then
sometimes you will need to keep at it. You may even need to push the
issue high up in the organization.
Third, support change.
What we need, for starters, is for the government to enforce the
current law. The law is explicit regarding your right to access your
health information. Your rights
under federal law need to be respected. When your rights are violated,
you can contact the Office for Civil Rights or your congressional
representatives for help. What you do may help the next person.
are reasons for optimism. For instance, there is work on tools to help
people obtain their data more easily. (Disclosure: I founded a startup
that developed a tool called Hugo, a platform to help people get their data digitally.)
Groups such as OpenNotes
are setting an example by encouraging access to all our health care
data and encouraging patients to read their health care provider’s notes
and records as a way to improve their care.
With the Trump administration’s interest in interoperability of medical records,
I hope that we are on the cusp of a historical moment when people will
finally get full access to their digital data, as specified under the
When patients have easy access to their data, they will
have the chance to use that data for their own benefit and the benefit
of others. This could be a transformational shift giving patients more
power to shop for their care, to understand their care and to become
true partners in research.
We’ve all heard the saying, “age is just a number.” Nowhere is that more important than in the hospital setting.
Over the years, I’ve become more and more aware of ageism in health
care — a bias against full treatment options for older patients.
Assumptions about lower capabilities, cognitive status and
sedentary lifestyle are all too common. There is a kind of “senior
profiling” that occurs among hospital staff, and this regularly leads to
inappropriate medical care. As a physician myself, I’ve seen it.
Misconceptions Prompt Misdiagnoses
Take for example, the elderly woman who was leading an active life in
retirement. She was the chairman of the board at a prestigious company,
was an avid Pilates participant and the caregiver for her disabled son.
A new physician at her practice recommended a higher dose of diuretic
(which she dutifully accepted), and several days later she became
delirious from dehydration. She was admitted to the local hospital where
it was presumed, due to her age, that she had advanced dementia.
Hospice care was recommended at discharge. All she needed was IV fluids.
Hospitalized patients are often different than their usual selves. As
we age, we become more vulnerable to medication side effects,
infections and delirium.
I recently cared for an attorney in her 70s who had a slow-growing
brain tumor that was causing speech difficulties. She, too, was written
off as having dementia until an MRI was performed to explore the reason
for new left-eye blindness. The tumor was successfully removed, but she
was denied brain rehabilitation services because of her “history of
I recently wrote about my 80-year-old patient, Jack, who was presumed to be an alcoholic when he showed up to his local hospital with a stroke.
Not Their Usual Selves
Hospitalized patients are often very different than their usual
selves. As we age, we become more vulnerable to medication side effects,
infections and delirium. And so the chance of an elderly hospitalized
patient being acutely impaired is much higher than the general
Unfortunately, many hospital-based physicians and surgeons — and
certainly nurses and therapists — have little or no prior knowledge of
the patient in their care. The patient’s “normal baseline” must often be
reconstructed with the help of family members and friends. This takes
precious time and often goes undone.
Years ago, a patient’s family doctor would admit him or her to the
hospital and provide care there. Now that the breadth and depth of our
treatments have given birth to an army of sub-specialists, we have
increased access to life-saving interventions at the expense of knowing
those patients who need them.
Tests Could Be Prevented
This presents a peculiar problem — one in which we spend enormous
amounts of resources on diagnostic rabbit holes because we aren’t
certain if our patients’ symptoms are new or old. Was Mrs. Smith born
with a lazy eye or is she having a brain bleed? We could ask a family
member, but we usually order an MRI.
My plea is for health care staff to be very mindful of the tendency
to profile older patients. Just because Mr. Johnson has behavioral
disturbances in his hospital room doesn’t mean that he is like that at
home. Be especially suspicious of reversible causes of mental status
changes in the elderly, and presume that patients are normally
functional and bright until proven otherwise.
Going Strong at 103
Last month I hit a new age record at my rehab hospital — I admitted a
charming, active, 103-year-old woman after a small stroke caused her
some new weakness. She was highly motivated in therapy, improved
markedly and was discharged to an independent living center. I bet she
will live many more years.
When I joked that she didn’t look a day over 80, she winked and told
me she had stopped counting birthdays years ago. She said, “It doesn’t
matter how old you are, it matters what you can do. And I can do a lot.”
Women are at higher risk of stroke, and have a higher mortality rate. Be aware if you are in this category, be closely monitored, and maintain the habits of a healthy lifestyle.
Women Who Are Most at Risk of Stroke
— Robert Preidt
THURSDAY, Feb. 8, 2018 (HealthDay News) — Stroke affects more women than men in the United States. And a new study pinpoints stroke risk factors unique to females.
“Many people don’t realize that women suffer stroke more frequently than men, and mortality is much higher among women,” said Dr. Kathryn Rexrode, the study’s corresponding author.
“As women age, they are much more likely to have a stroke as a first manifestation of cardiovascular disease rather than heart attack,” said Rexrode, who is with Brigham and Women’s Hospital in Boston.
The study attempts to better understand susceptibility, she said.
“Why do more women have strokes than men? What factors are contributing and disproportionately increasing women’s risk?” Rexrode said in a hospital news release.
Stroke affects 55,000 more women than men each year in the United States. It’s the leading cause of disability and the third leading cause of death in women, the researchers said in background notes.
Rexrode’s team analyzed the scientific literature and identified several factors that increase stroke risk in women. These include:
Menstruation before age 10,
Menopause before age 45,
Low levels of the hormone dehydroepiandrosterone (DHEAS),
Use of birth control pills.
A history of pregnancy complications can also indicate higher stroke risk. These problems include gestational diabetes and high blood pressure during or immediately after pregnancy, the researchers said.
Some of these risk factors are common, and the researchers stressed that few women who have one or more will suffer a stroke. However, they said it’s important for health care providers to be aware of any heightened risk.
“These women should be monitored carefully and they should be aware that they are at higher risk, and motivated to adhere to the healthiest lifestyle behaviors to decrease the risk of hypertension (high blood pressure) and subsequent stroke,” Rexrode said.
The paper was published Feb. 8 in the journal Stroke.
Patients and their healthcare providers need a shared language. There’s a distinction between achieving a strategy, objective, and goal. For example, a patient-client wanted to use weight-lifting (strategy), to develop her upper body strength (objective), so she could easily pick up her grandchild (goal).
Achieving Your Personal Health Goals: A Patient’s Guide
Dr. James Mold, a family physician and author of Achieving Your Personal Health Goals, says doctors should work with their patients to set mutually agreed-upon goals throughout life.
Many of us make New Year’s resolutions. Few of us realize them. Maybe it would help to reframe how we handle our resolutions by thinking of them as goals instead.
What health goals will you reach for in 2018? And which, if any, will you discuss with your doctor?
A new book, Achieving Your Personal Health Goals, is a patient’s guide for setting life goals and also planning for the inevitable end. It’s a shift from the usual medical framework that looks at health improvement as a set of problems of sickness to be solved.
Family physician and geriatrician James Mold, who wrote the book, has spent more than a quarter-century thinking about how to use goals to improve health care.
Mold is one of only four Oklahomans ever to be inducted into the prestigious National Academy of Medicine. He’s now retired and living in his native North Carolina, so I was pleased to be able connect with him recently in an interview for Public Radio Tulsa’s Medical Monday.
Here are highlights from our conversation, edited for length and clarity.
Forgive me for asking, but isn’t all health care directed by goals?
You would think so. The concept is that people’s own attention to their health should be directed at some sort of goal that makes sense in how they view health.
If you think health involves living as long as possible, or at least living until life no longer seems worthwhile, then you should do things that help you achieve that goal.
Doctors tend to focus on strategies and not goals. The assumption is that if you do the strategies well — that is, if you cure disease and solve all the health problems — that the goals will take care of themselves.
It worked really well when most of the health problems that we saw were infections or injuries. But it doesn’t work as well for other things — particularly things we deal with these days, like diabetes, hypertension, obesity and alcoholism — those things that aren’t easily treatable.
What if someone had diphtheria and we cured it? Isn’t cure the goal?
A goal is something you want to have happen where it doesn’t make any sense to ask why would we want to have that happen.
Curing diphtheria is not really a goal but a strategy — the goal is to keep you alive. And keeping you alive is a goal because it doesn’t make sense to ask why would you want to stay alive.
We tend to view aging as inevitable and disappointing. So by reframing care as goal-directed aging, then getting old is less a problem than a part of life, right?
My mother, before she died, wanted to improve her balance (a strategy), so that she could get rid of the walker (an objective) so that she could go back to gardening (her goal).
It’s really important to be clear about what a goal is, because if you don’t understand what a goal is, then goal-directed care is no different from what we’re doing now.
Your book is written for patients. You make the point that goal-directed care is mutually agreed upon between doctor and patient. It’s the patient’s goal that the doctor can help the patient clarify and achieve, correct?
No, it’s a negotiated settlement, if you will. One of the nice things about goal-directed care is that it puts the doctor and the patient on equal footing so that they both have something to contribute to the discussion. So the patient knows what their values and preferences are, and what they’re able and willing to do, and the doctor knows what is possible to do. If you put that information together, you come up with something that’s reasonable.
I remember a patient vividly in a small town in North Carolina who came in every week to have her blood sugar checked, and it was always out of control. I did everything I could to advise her as to how to get it under control. So I put her in the hospital and her blood sugar came right down to normal. I told her she really didn’t need to come back every week until she did the things I told her to do. It wasn’t’ going to be under control. And she fired me!
I later learned the reason that she came in every week was because it was a social event for her; she knew everybody in the practice. She saw people in the waiting room and got some attention and she felt the only way she could do that was to keep her blood sugar out of control.
I totally misunderstood that. I think it would’ve been a lot clearer if we could have agreed on the goals up front. Whether I could have gotten that goal from her, if she would’ve admitted to that, I don’t know. But at least we would have had an opportunity to figure out what was going on.
What about goals near the end of life?
Since medical school, one of my missions in life is to try to make medical care more humane. I became a family physician because I thought that was the field that was talking the right talk. By the late 1980s it seemed that the revolution had moved to the field of geriatrics, so I became a geriatrician.
As a geriatrician, I was faced with lots of folks who had incurable problems, and who, as they aged, became less and less functional and less able to participate in meaningful life activities.
I worked at a rehab institute that I helped to establish. We worked with occupational, physical and speech therapists, and they were talking about goals. That’s the first I’d ever heard about the term “goal” in medicine, at least in the sense that I think of it now. That got me thinking, “Why don’t we think in terms of goals?”
Doctors didn’t understand why we needed to think that way. Geriatricians sort of got it.
Since 1991 I’ve been trying to convince doctors that this might be a better way to think, with very little success. One of my non-physician colleagues told me to write a book for patients — that they would get it, and perhaps they could demand a change in the health care system.
The Braille Institute of America knows every 7 minutes someone in the U.S. loses their sight, often as a part of the aging process. Here are 10 essential tips for setting up a home, or accommodating a visiting person with limited vision. It’s information we can all use!
Vision Loss: 10 Vital Tips for Anyone living in or visiting the home
By Rosalie Weatherhead, Owner at My Healthcare Advocate
DO NOT MOVE ANYTHING unless you put it back exactly where you found it. Visually impaired people have it down precisely how far back or far away from something a thing is. Moving it can cause confusion and frustration as they search by feel for it.
CONTRAST COLORS. We are used to black on white, like this article, but in fact many visually impaired people see better with light writing on a dark background.
LOTS OF LIGHT. Open curtains, turn lights on, let the sunshine in! Low Vision sufferers see better in well lit conditions, allowing a better definition of objects and contrast of color and light.
BEWARE OF HAZARDS lurking below the knees. Do a walk around focusing on the area below the knee, are there any obstacles hiding against the baseboards or protruding from the walls?
DOORWAY TO HELL. Most doorways, especially in modular and mobile homes aren’t wide enough to fit a walker or wheelchair. Look for door wideners (offset hinges) that can amazingly expand doorway widths 2 inches.
LOOKING GLASS. Glasses help even when they don’t make reading better. Glasses sometimes help with balance, as it keeps focus in a smaller area and allow the brain to adapt.
HAZARDOUS MATERIALS. Rugs. Knives in a drawer. Metal tops from opened cans. Round objects not in a container. Animals. Ice Makers on door of fridge. Loose Wires. What else?
MY MARKER, MY FRIEND. Use a large black marker to make recognizable marks on Medicine tops, cleaners, can tops, anything that has small writing.
TV LISTING. Seems so simple, doesn’t it? But if you can’t see the TV you have to listen, and if you can’t see the channel, you can’t go to a program you want to listen to. Also, make a list of favorite programs in large print with the channel listed next to it.
LAST BUT NOT LEAST. Contact your state’s Commission for the Blind. They provide vision exams, visual aides, and even voice recognition training and software when approved.